Causes of infertility: investigation and treatment

Investigation of infertility causes and treatment with the use of the newest methods at Northway Fertility Centre.

In 2016, Northway Medical and Surgical Centre conducted training on Transvaginal Endoscopy with the participation of Gints Treijs, Juris Vitols, and Egils Gasinsthe, the well-known infertility specialists from “Embrions” Medical Centre for Reproductive Medicine in Riga. During this training, Rolandas Žiobakas, an obstetrician gynaecologist from Northway Fertility Centre, shared his experience on the optimal usage of minimally invasive endoscopic methods of diagnostics in the identification of possible causes of female infertility as accurately as possible.

In connection to this, we spoke to Rolandas Ziobakas, obstetrician gynaecologist, about the newest methods of infertility diagnostics and treatment.

What kind of challenges in diagnostics and treatment of infertility do you find in patients you have seen?

The requirements set by couples that face infertility problems have changed in recent years. The family wants to have a child instead of undergoing tiresome examinations which take much time. It is a common case when a couple facing infertility problems spends a lot of valuable time without having a knowledge of or being unable to access information on how to find the possible causes of infertility within the short period of time. Meeting with these couples often reveal that examination of their infertility does not go beyond an assessment of men’s semen analysis, an ultrasound of internal female genital organs and diagnosis of possible venereal infections. On the other hand, such widespread examination methods as an ultrasound of internal female genital organs and a hysterosalpingography involving X-rays are minimally invasive, but their diagnostic value is very limited given that a woman has pelvic adhesions, including intrauterine adhesions, an endometriosis, ovarian disorders, etc.

Which actions determine protracted time prior the pregnancy?

Key factors include age, usage of contraceptive agents, and disorders which can be diagnosed and effectively treated with the help of the endoscopy.

When is the right time to consult an infertility specialist?

First of all, based on modern views and data from epidemiological research, a woman should apply for diagnostics of infertility causes if she does not succeed in becoming pregnant within one year. But there are exceptions. If a woman is 36 years or older or has any obvious cause that can possibly determine infertility, for example, menstrual disorders, previous inflammations in the genital area, injuries, surgeries, radiation therapy or chemotherapy, it is recommended to apply for diagnostics earlier after trying to become pregnant within six months.

How can you describe the principles of modern infertility diagnostics?

The main challenges of infertility diagnostics we face today can be described in the following way: diagnostic testing of infertility must be initiated if a woman unsuccessfully attempts to become pregnant within 6-12 months, the testing itself must be minimally invasive, very precise and immediate without distracting the couple from their professional activities and giving the couple explicit recommendations and further treatment guidelines. On the other hand, occupational opportunities for infertility specialists have also increased.

What is a Transvaginal Endoscopy?

In 1998, Stephan Gordts, a gynaecologist from Leuven (Belgium) Institute for Fertility & Embryology (L.I.F.E.) with his colleagues first conducted and described the new infertility examination technique of transvaginal endoscopy.

It is known that transvaginal ultrasound testing and radiologic hysterosalpingography (HSG) provide insufficient data, while a laparoscopy is heavily invasive method that gives no obvious data on pelvic disorders. Based on the above-mentioned modern principles, women are recommended to take a Transvaginal Endoscopy (TVE) to investigate reproductive organs, including a hysteroscopy, transvaginal hydrolaparoscopy (TVL) and a chromosalpingoscopy as a first-line infertility investigation. The atraumatic procedure of diagnostic hysteroscopy involves using a 2.4-mm diameter continuous-flow endoscope without the usage of any vaginal dilator, forceps, and without dilating the cervix or using any anaesthesia and analgesics. Studies have proven that diagnostic hysteroscopy performed before the planned In-Vitro Fertilisation (IVF) procedure helped to reveal an intrauterine disorder (adhesions, polyps, submucous myoma, etc. (Oliveira, 2004) in 28-45% of cases which were not previously diagnosed. A hysteroscopy is a much more superior technique for evaluation of the endometrial cavity in comparison with an ultrasound hysterosonography because it can additionally evaluate mucosal alterations in the uterus, including other types of “subtle” alterations. Transvaginal laparoscopy is recommended for patients without obvious pelvic pathology which could not be revealed clinically or by an ultrasound. TVL is performed under intravenous sedation with the help of a specially developed needle-trocar system through a needle puncture of the posterior fornix and insertion of a 2.4 mm endoscope (a similar one used for a diagnostic hysteroscopy). Then 150-200 ml of fluid is instilled through it into the peritoneal cavity to explore the oviducts, ovaries, pelvic organs, and to take a tubal patency test, a chromosalpingoscopy. After the procedure, the solution exits from the operative port of the endoscope. Female patients tolerate this procedure well. The percentage of complications is very low (0.74 per cent). Transvaginal hydrolaparoscopy helps uncover pelvic abnormalities in 26-56% of cases when these abnormalities failed to be discovered during the procedure of a hysterosalpingography. In general, a radiologic hysterosalpingography is being rarely performed in such European countries as Belgium and Holland due to providing insufficient information and undesired effects.

Your Fertility Centre’s team demonstrates great results in infertility treatment, so it must make you really happy for helping many families to have children. What contributes most to the success?

The main goal of Northway Fertility Centre’s specialists is to determine the cause of infertility as precisely as possible in order to prescribe an effective treatment so the family can succeed in having a child. Northway Medical and Surgical Centre is the only private medical centre in Lithuania that offers a versatile evaluation of infertility by the use of minimally invasive transvaginal endoscopic methods and succeed in treating infertility with the help of an advanced and effective infertility treatment techniques. Procedures of Transvaginal Endoscopy are performed in the modern operating theatre at Northway Surgical Centre within one day. After the procedure, the patient receives all the necessary information in details and a treatment plan for further infertility treatment for the couple.

Minimally invasive gynaecological surgery at Northway Medical and Surgical Centre means not only a conservative method of surgical treatment but also a fast recovery and getting back to everyday activities.

Why is a versatile and precise investigation of causes of infertility so important?

It is a common knowledge that the cause of infertility remains unexplained in up to 30% of the cases. Due to the unknown origin of infertility, the couple is advised to use the Assisted Reproductive Technologies, such as Intrauterine Insemination (IUI) or In Vitro Fertilization (IVF). However, even today we encounter the situation wherein these complicated and expensive treatment methods are being recommended for couples that did not undergo a comprehensive infertility evaluation, and consequently such an approach led to the problem of infertility being left behind without solving it. Previously undiagnosed uterus abnormalities (partial uterine septums) as small myomas distorting the uterine cavity, intrauterine adhesions which prevent from successful embryo transplantation and pregnancy can be set as an example. Furthermore, a positive tubal patency testing does not provide us with information about the mobility of fallopian tubes and ovaries in the case of endometriosis because an ovary fixed by endometriotic adhesions can represent an obstacle to successful ovulation and oocyte entry to the fallopian tube. Answers to all of these questions can be received and solved after conducting a comprehensive and minimally invasive investigation involving a diagnostic hysteroscopy and transvaginal hydrolaparoscopy.